Aging Population in India: The Health System Role of Traditional Medicine- Unnikrishnan Payyappallimana

Aging Population in India: The Health System Role of Traditional Medicine

Unnikrishnan Payyappallimana

Introduction

India has experienced a major demographic transition in the past few decades resulting in a substantial increase in the aged population. Consequently there is increasing burden on the health system. Neither the current healthcare infrastructure nor the professional capacity is equipped to handle this situation. This is further challenged by the fact that there is no social security system in the country and over 80 percent of the health care is accessed through out of pocket expenditure. Changing social support systems, rapid urbanization, deteriorating environment further complicate the situation.

In this context, the article explores the relevance of traditional systems of medicine in the country for improving healthcare for the elderly population. The article briefly highlights certain unique principles and features of traditional systems of medicine in geriatric care by focusing on Ayurveda, the most popular traditional medical system in the country. The article takes two fold approaches to address the challenges i.e. from the point of view of individual care what measures are desired and from a health system focus what policy directions are needed to integrate these systems into geriatric care.

Indian life expectancy has increased by 25 years in the last 5 decades. This has resulted in tripling of elderly population in the country. India is going to become the second largest country in the number of elderly in the world. It is expected that by 2026, 12.4 percent of the population will be in the above 65 age category (Patwardhan 2012, Dey et al. 2012). Extrapolated figures indicate that elderly population (60+ age group) will be 100 million in 2013 and will raise to 198 million by 2030 (Government of India 2011). Two thirds of the elderly population live in rural areas and around half of them have poor socio economic status thus making health service a major challenge (Dey et al. 2012). Due to the diverse stages of social, political and economic development there is considerable disparity among Indian states in the demographic transition and their consequences. It is anticipated that the South India will face a faster transition as compared to the North owing to this.  Another critical fact to take note of is that around half of the elderly population is dependent and 70 percent of elderly are women (Dey et al. 2012). It is estimated that 51% of Indian elderly will be women by 2016 and compared to males, women have poorer health status (Government of India 2011).

Health Systems Challenges in an Aging Society

International instruments such as the United Nations Human Rights Commission, Millennium Development Goals (MDGs) and the World Health Organization (WHO) have increasingly acknowledged access to appropriate healthcare as a human right. At the same time the situation of the aging population in the country is challenged by the fact that the health system is not adequately equipped to take care of these emerging needs. There is a huge out of pocket expenditure of almost 83% for outpatient care which is not covered by any insurance at all (Duggal 2007; 2009). Availability, accessibility and affordability of health services continue to be major issues. Declining social support systems, reduction in disposable income post-retirement, family nuclearization, lack of appropriate social security policies, increasing chronic disease morbidity, high diversity and heterogeneity in different regions in the country, reduction in post retirement earning, gender, caste and religious based inequities are some of the key contributing factors. Elderly health is also dependant on several other factors such as marital status, education, economic freedom, sanitation and so on (Dey et al. 2012). According to the 2004-2005 National Family Health Survey, only 10% of the households had atleast someone in a family covered under any type of health insurance. Only the privileged groups of the society avail insurance coverage and most needy are left out. Often elderly are excluded from insurance coverage due to certain age limits or based on their previous health status (Dey et al. 2012).  Due to reduction in income postretirement most are unlikely to be able to pay the insurance premium regularly.

Being a transition economy with huge diversity and disparity, the pattern of morbidity has been quite unique in the country. While infectious diseases continue to exist, chronic diseases have already reached epidemic proportions. This places a huge stress of the health system. According to the 60^th round National Sample Survey around 8% of the elderly population is confined to home or bed and 27% of those aged 80 years are bedridden (NSSO 2006).

Traditional Health Systems and Their Role

The following section gives an overview of traditional systems of medicine and examines their role in addressing healthcare challenges of elderly. Traditional medicine refers to health practices, approaches, knowledge and beliefs incorporating plant, animal and mineral based medicines, spiritual therapies, manual techniques and exercises, applied singularly or in combination to treat, diagnose and prevent illnesses or maintain well-being.” (WHO 2002) Further the term complementary and alternative medicine (and sometimes also non-conventional or parallel) are used to refer to a broad set of healthcare practices that are not part of country’s own tradition, or not integrated into the dominant healthcare system. This is a broad and inclusive definition which makes it difficult to find a region or a country without any form of traditional medicine. It is often known through a variety of names such as traditional medicine, alternative medicine, complementary medicine, natural medicine, herbal medicine, phyto-medicine, non-conventional medicine, indigenous medicine, folk medicine, ethno medicine etc., based on the context and the form in which it is practiced. Chinese medicine, Ayurveda, Herbal medicine, Siddha, Unani, Kampo, Jamu, Thai, Homeopathy, Acupuncture, Chiropractic, Osteopathy, bone-setting, spiritual therapies, are some of the popular, established systems (Payyappallimana 2010).

There is an emergent interest in both developed and developing countries to integrate traditional medicine/complementary and alternative medicine (TCAM) in public health systems. Diversity, flexibility, easy accessibility, broad continuing acceptance in developing countries and increasing popularity in developed countries, relative low cost, low levels of technological input, relatively low side effects and growing economic importance are some of the positive features of traditional medicine (WHO 2002, Payyappallimana 2010).

Though these systems differ in their approach to clinical principles or management methods they share a common worldview. According to this the macrocosm (outside universe) and microcosm (living being) are inherently related and have common elements. These systems also have similar perspectives such as ecological centeredness, an inclusive approach to non-material or non-physical dimensions, and holistic approach to health management considering physical, mental, social emotional, spiritual, ecological factors in health and wellbeing. “Fundamental concept is that of balance - the balance between mind and body, between different dimensions of individual bodily functioning and need, between individual and community, individual/community and environment, and individual and the universe. The breaking of this interconnectedness of life is a source of dis-ease,” (Bodeker 2009: 37). Other unifying attributes are their popular and public domain character and orientation to prevention and self help. Mostly these systems focus on the functional aspects of health and diseases, whole system approach to health, multi-causality, subjective, qualitative, individualized and personalized management and consider both physician and patients both as active agents in healing.

According to WHO between 60-80% of the population in developing countries and a growing percentage in developed countries continue to avail services of traditional medical systems (WHO 2002). However the slow official response shows the lack of correspondence between public choice in health seeking behavior and the policy processes in different countries. Proof of efficacy, quality, safety and rational use continue to be major challenges in the sector. Increase in chronic diseases, better awareness about the limitations of conventional medicine, growing interest in holistic preventive health, increasing evidence of clinical efficacy, better clinical care, easy access especially in rural areas and cost efficacy are some of the key reasons for the resurgent interest in traditional medicine. In countries like India the per-capita ratio of practitioners of TCAM is higher compared to conventional medicine. In rural areas easy access, availability and cost are key aspects of utilizing traditional medicine whereas in urban areas it depends on concerns about chemical drugs and interest in natural medicines, limitation of conventional medicine, greater information access are some of the reasons for accessing traditional medicine. Thus in a public health context availability, accessibility, affordability, utility, quality, efficiency and equity become relevant in accessing healthcare (Payyappallimana 2010).

Indian Context of Traditional Medicine

In the subcontinent varied forms of codified medical systems such as Ayurveda, Siddha, Unani or Tibetan medicine (Gso-wa-rigpa) have long coexisted along with a rich non-codified folk form of knowledge. There are also several allied disciplines of traditional medical knowledge such as yoga and several newly introduced knowledge streams. The codified knowledge systems like Ayurveda have evolved in last 3-4 millennia and have unique worldviews, conceptual and theoretical frameworks for health management. The current available oldest Ayurveda literature is codified in 300 BCE which shows its antiquity. These systems have their distinctive understanding of physiology, pathogenesis, pharmacology and pharmaceuticals which are different from Western medicine. These systems have been institutionalized through national councils, uniform syllabus and education systems. In India there are around 800,000 licensed practitioners belonging to these medical systems, a huge human resource for any public health intervention. Much more diversity is available in the folk knowledge traditions otherwise known as local health traditions which are community specific and ecosystem specific. They use locally available medicinal plants and other resources for healthcare. They include an array of practices such as household level health practices (home remedies, food and nutrition, health related rituals and customs etc.) to specialized healers treating fractures, poison, pediatric ailments, skin disorders, mental health and so on. They are mostly orally transmitted, and highly dynamic. Though they differ substantially based on the ecosystem in which they are practiced they share common value systems and similar modes of transmission in communities. These are not legally recognized and often considered invalid yet continue to exist in communities due to social legitimacy and patronage.

Apart from these native traditions there also exist an extensive machinery of homeopathy practitioners which has been institutionalized in India and comes under the department of AYUSH[1], the Ministry of Health and Family Welfare. The traditional medical resources also include allied disciplines such as yoga, various approaches of meditation, breathing, martial arts, marma chikitsa, massage techniques which contribute to health and wellbeing. There are also new forms of complementary and alternative medical (CAM) knowledge which have been imported from other countries in the recent decades and have become popular like acupuncture, phytomedicine or herbal medicine, osteopathy, reiki, shiatsu, and so on which do not have formal recognition yet practiced in India.

Life, Health and Aging in Ayurveda

This section examines how Ayurveda, a major Indian traditional medical system views aging and what healthcare response is feasible from the point of view of Ayurveda. Caraka Samhita, the olderst traditional treatise available today starts with a chapter on long life (deerghamjeeviteeyam). The mythological origins of ayurveda according to this chapter is that great ascetics disturbed by diseases in their religious observances due to worldly indulgence, gathered in the abode of Himalayas to seek a solution to the problem. Wishing for a long and healthy life they sent Bharadvaja as their representative to Indra, the king of devas, who had received the knowledge through a lineage originating from Brahma. Brahma in turn revealed this knowledge of life to the ascetics through Bharadvaja. Whereas the mythical origins and anecdotes may have layers of meanings intertwined in the cultural context what is most interesting is Ayurveda’s pursuit for healthy and long life imprinted in these lines.

The term Ayurveda is comprised of two words Ayu (longevity of life) and veda (knowledge), the word Ayu is further explained as sukha ayu (happy life), hita ayu (sustained happiness), and deerghayu (long life) thus extending the definition of longevity to include a holistic approach to health and wellbeing. This perfectly signifies the role of Ayurveda in geriatric care. Health according to Ayurveda is a balance of structural and physiological principles (dosas and dhatus) of the body, excretory mechanism (mala), and a balance of self (atman), sense organs (indriya) and mind (manas). Ayurveda has primarily a predictive and preventive approach to healthcare management with self awareness and self reliance as its focus. From this perspective health is a state when one is established oneself (svastha). This is based on the understanding that each individual is born with a specific constitution and predisposition for health and disease. Maintaining the balance of one’s constitution (which is unchangeable though tendencies can be modified to certain extent) is healthy state while promoting a positive approach to health and wellbeing.

Though the exact cause of aging is not discussed in detail, it is mentioned that it is a natural state of ‘disease’ (svabhavabala roga) among other such six other states such as hunger, thirst, sleep, and death. Describing that no cause is needed for natural decay, Caraka says that the growth or deterioration depends on two factors such as daiva (effects of the past) and purusakara (efforts of present life). By stressing the importance of time (kala) Caraka says growth depends on place and time of birth; quality of seed and soil; diet; mind; natural mechanism; physical exercise; cheerfulness etc., which are essential for growth (Tiwari and Upadhyay 2009).

According to most Indian traditional medical systems there are three dosas (roughly correlated as humors) in the body namely kapha (nourishment principle), pitta (transformation), vata (movement and destruction). Starting from early stage of life, nourishment, transformative and movement and destruction factors will be strong respectively. In other words towards late stages of life vata principle manifests strongly in the body thus leading to diseases of neuromuscular and musculoskeletal conditions. Apart from this, each individual by birth acquires either singular or a combination of the characteristics of these dosas known as prakriti (physical and mental constitution). Similarly every factor such as seasons, geographical regions, tastes, food items, medicinal plants and so are classified on the basis of the relative preponderance of these dosas. These are cardinal principles in understanding the predispositions of health or disease, diet, lifestyle or suitable medicines for an individual. Equilibrium of these principles is the desired state of health.

Geriatrics is one of the eight core branches of Ayurveda since its written history. Rasayana or jara chikitsa mainly deals with rejuvenation, improving growth and reducing deterioration of the body. Jara indicates a process of reduction in lifespan due to changes in the body (Tiwari and Upadhyay 2009). This encompasses concept of vayasthapana (stabilizing or regulating aging), rejuvenation, regeneration, immunomodulation and so on. There are different approaches to rasayana (Patwardhan 2012).  Early aging which is an unnatural state can be prevented by this treatment, at the same time it can slow down the process of natural aging. Rasayana also encompasses other topics such as healthy living and social conduct. Treatment regimens and medicines have effects on promoting longevity, strength, stabilizing and regulating aging, promoting intellect, memory, alertness and minimizing fatigue (Badithe and Ali 2003).

There is also a systematic approach to social and community health involving an intricate psychosomatic approach. Svasthavrita (healthy regimen or preventive care) a central tenet of ayurveda reinforces this approach through elaborate daily and seasonal practical advices.

Coming to the curative dimension, some of the major diseases encountered during old age are arthritic conditions, rheumatic and neurological conditions, dementia, Alzheimer’s disease, psychiatric disorders, physical disabilities due to injury and slow healing, skin disorders, impairment of sense organs (chiefly visual and hearing impairment), mental morbidities like anxiety or depression due to social isolation and feeling of alienation, lack of immunity and infections like pneumonia, tuberculosis (multidrug resistance), dietary problems of  the aged mainly due to teeth loss, low backache, chronic bronchitis, hypertension, digestive disorders, aneamia etc. Additionally for those who already suffer from chronic conditions like diabetes, cardiovascular disease the secondary effects during old age can be challenging. In stages of conditions with syndromic nature, conventional symptomatic medications like those for pain, antidepresents, anti-inflammatory agents, laxatives cannot address the basic cause, may create dependency on these medicines and chronic after effects. This can also lead to loss of autonomy, inactivity and so on. In such stages there is a definite preventive, curative, promotive and palliative role that traditional management regimens can contribute to. Apart from these ayurveda advice on diet which is constitutionally and seasonally planned, physical exercises based on yoga or other exercise forms especially sensitive to brittle bones and joints have an important function. Spiritually oriented meditative exercises, breathing techniques, daily and seasonal diet and lifestyle modifications based on traditional medical principles, personal and social behavior and so on also have key contributions to make.

Panchakarma therapy consisting of major purificatory and rejuvenative management methods as per ayurveda also has an important role in geriatric care. For instance regular oil application based on the individual constitutional specificities and health condition requirements is a good support for maintaining health. This would help reduce the healthcare costs. Early monitoring and surveillance can also produce good results.

Apart from the formalized, institutionalized traditional medical systems, local health traditions also has a lot to offer in rural healthcare and especially in areas like gender specific interventions due to the fact that public health facilities are often not used by women.

Need for Policy Support

The approach to universal health coverage and health system development in India is predominantly based on modern medical approach. In the National Health Mission programs traditional medicine is integrated marginally and mainly in the form of dispensable medicines and not as a holistic health care approach. In most national programs traditional medicine appears in the form of inclusive, politically correct, tail-end statements. Why are Ayurveda and other traditional medical systems not called for to address the healthcare challenges of the elderly? There is a lot that TRM can offer in terms of preventive care, healthy lifestyles, early detection of likely manifestation through methods such as prakriti analysis, treatment methods such as panchakarma particularly in the case of chronic, debilitating conditions. National program for Health Care of the Elderly is a comprehensive health strategy by Ministry of Health and Family Welfare. Such programs should integrate holistic practices of AYUSH systems and their infrastructure not as pilot schemes but as large scale interventions across the country. This requires creation of traditional medicine resource centres, capacity building for medical and paramedical professionals with special focus on the strengths of TRM in chronic care. This also requires continuous generation and updation of evidence base for the TRM management. This would enhance the confidence among AYUSH professionals on their relevance in gerontology. This is important as public health today is an unfamiliar terrain for AYUSH professionals. It is a welcome move that AYUSH department has promoted Centres of Excellence in Geriatrics in the recent past. These centres should actively engage in research and capacity development in the sector. It is also important to promote geriatrics focused education in undergraduate and postgraduate AYUSH programs in the existing academies of traditional medicine in the country.

In policy discussions on traditional medicine multilateral bodies have given broad guidelines on how to systematize traditional knowledge with due consideration to quality, safety, efficacy and rational use. These issues will have to be addressed for any traditional medicine based public health intervention. One of the hurdles with respect to traditional medicine is the widespread quackery and cross system practices that exist in the guise of TRM. Continuous surveillance systems need to be established for monitoring safety of these practices. Inorder to assure quality, rational drug use and cost efficiency, essential drug lists with region specific requirements are a must.

An important dimension that any traditional medical intervention should create is self reliance in management of primary healthcare problems of the elderly. It should also promote a positive approach to health and wellbeing as well as improve resilience of elderly population. As a rural community based self reliant healthcare model, India as a biodiversity rich region of the world has immense potential in developing a locally driven healthcare and nutrition development model particularly for regions where health access poor, yet are natural resource rich in the country. Such an approach is especially important for reducing healthcare costs while assuring self reliance among communities. This also requires enormous commitments from the professional medical fraternity for planning, implementing and monitoring of such community centred health delivery programs.

Finally, elderly population requires long term, regular care which calls for systems of care of a longer term basis. In a country like India which is based on family care taking, home care givers have a significant role to play. Home care workers need special training in geriatric care through traditional medicine in particular in the area of neuromuscular, musculoskeletal and other degenerative conditions. Many studies show also that family continues to be primary care giver in the country. This calls for better awareness among households about the various management approaches of elderly care among family members. There should be capacity both for family members and care givers for systematically giving feed back to the health system. This will help develop a need based primary healthcare approach. Adequate knowledge and awareness of health conditions, their prevention or treatment, healthy lifestyle are necessary for implementing such public health interventions.

Conclusion

It is clear that informal care is far important than formal care in the area of geriatric care chiefly in countries where family care has been the norm, and as no government can provide for the demands of a fast aging population. Approach to elderly care should be based on the vision of reinforcing family and community based care in a locally driven process appropriately harnessing locally available resources and knowledge. One of the rich resources that the country possesses is the strength of its traditional knowledge systems and the abundant natural resources in the form of medicinal plants and nutritional resources. The traditional systems have different and unique approaches to healthcare. Methods like rasayana which are means to revitalize ailing and aging bodies have not been adequately studied and thus needs due research consideration. As Patwardhan (2012) notes, going by the recent statement of the World Health Organization, integration such a holistic health care approach is definitely likely to yield ‘not just years to life but life to years’.

References

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(Dr. P. M. Unnikrishnan is Research Co-ordinator of the UN University Institute of Advanced Studies at Tokyo.)

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[1] AYUSH department under the Ministry of Health and Family Welfare is the apex body for regulating Ayurveda, Yoga, Unani, Siddha and Homeopathy systems in the country.